Information Collection

Flint Rash Investigation

IC 221128 under ICR 201509-0923-002 · OMB 0923-0051.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0051 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Flint Rash Investigation	Form and Instruction
Follow-Up Flint Rash Dermatology Report Form Att B Flint Rash Dermatology Follow-up Report Form.docx	Form and Instruction
Att A MDHHS Derm Follow up assistance request 0419-2016.pdf Letter of Invitation	IC Document
SSB ACE Invstg Flint Rash Drmtlgy Fllw-up.docx Supporting Statement B	IC Document
Att C Flint Rash Dermatology Follow-up RDF Signed.pdf Research Determination	IC Document
Request ACE Investsgtn Form_Flint Rash Follow-up.pdf 0923-0051 GenIC Request	IC Document

IC Title:

Flint Rash Investigation

Agency IC Tracking Number:

16AEB

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	NA	Follow-Up Flint Rash Dermatology Report Form	Att B Flint Rash Dermatology Follow-up Report Form.docx	NA	No		Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title: 09-19-0001 Record of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances

FR Citation: 76 FR 4432

Number of Respondents: 150

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	150	150
Annual IC Time Burden (Hours)	25	25
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Letter of Invitation	Att A MDHHS Derm Follow up assistance request 0419-2016.pdf	04/19/2016
Supporting Statement B	SSB ACE Invstg Flint Rash Drmtlgy Fllw-up.docx	04/19/2016
Research Determination	Att C Flint Rash Dermatology Follow-up RDF Signed.pdf	04/19/2016
0923-0051 GenIC Request	Request ACE Investsgtn Form_Flint Rash Follow-up.pdf	04/19/2016

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.